The family physician suspected that the patient had erythema nodosum along with some pulmonary disease. She ordered a stat chest x-ray and bilateral hilar adenopathy with diffuse parenchymal infiltrates were seen (suggesting stage II sarcoidosis). The physician ordered an angiotensin converting enzyme (ACE) level, erythrocyte sedimentation rate test, complete blood count, and a comprehensive metabolic profile.
When the EN rash occurs with hilar adenopathy, the entity is called Lofgren’s syndrome. Lofgren’s syndrome can occur in tuberculosis, but a more common cause of Lofgren’s syndrome is sarcoidosis (as seen in this patient). Sarcoidosis, in particular, may present with EN lesions on the ankles and knees.
The physician treated the pain and discomfort of the nodules with ibuprofen. Oral prednisone for EN alone is controversial and should be avoided unless it is being used to treat the underlying cause (such as sarcoidosis). A referral was made to pulmonary medicine. It was expected that pulmonary function tests would be performed and prednisone might be initiated if the response to the ibuprofen was not sufficient.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Paulis R. Erythema nodosum. In: Usatine R, Smith M, Mayeaux EJ, et al., eds. The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009:756-759.
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